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Rehan Ahmed, David K. Coats, Michael T. Yen; Periosteal Flap Fixation of the Globe in Severe Strabismus. Invest. Ophthalmol. Vis. Sci. 2011;52(14):6372.
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Severe paretic and restrictive strabismus is often difficult to manage. Even despite aggressive surgical attempts at correction with large resection and recession of the extraocular muscles, patients often develop recurrence of large angle misalignments and anomalous head positioning. To provide a more stable post-operative alignment, patients may require globe fixation to achieve the goal of placing the eye in primary position. Although there have been several innovative surgical methods described, there has been no single agreed upon surgical modality to date to restore the eye in primary position and maintain that position over time. A technique that has been used at our institution with some success is the apically based periosteal flaps. Here, we present a series of patients who underwent periosteal flap fixation of the globe in the cases of isolated third-nerve and sixth-nerve palsies, multiple cranial nerve palsies, and severe ocular fibrosis syndrome. To our knowledge, this is the largest published series of patients who have undergone a periosteal flap fixation of the globe.
We performed a retrospective study at our institution of patients who underwent a periosteal flap fixation. In all cases presented, the creation of the periosteal flap was performed by an orbital surgeon, and the strabismus surgery and follow-up data points were performed and collected by a strabismologist.
A total of 8 patients underwent a periosteal flap fixation of the globe. The mean age was 48 years old. Three patients had a third cranial nerve palsy, 1 patient had congenital fibrosis, one patient had sixth cranial nerve palsy, and three patients had multiple cranial nerve palsies. Five patients had a medial periosteal flap constructed, and 3 patients had a temporal periosteal flap. The mean preoperative deviation was 48 prism diopters and mean postoperative deviation was 13 prism diopters, with a mean correction of 69%. Seven of the 8 patients had stable post-operative measurements, and a single patient required an additional procedure secondary to post-operative drift.
The surgical correction of severe paretic and restrictive strabismus is complex and can present a formidable challenge. The use of a periosteal flap at our institution has shown satisfactory outcomes not only with regard to improved post-operative deviation, but also in that most patients required only this single procedure, usually after several prior unsuccessful interventions.
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